First-in-Man Analysis of the Relationship Between Electrical Rotors From Noninvasive Panoramic Mapping and Atrial Fibrosis From Magnetic Resonance Imaging in Patients With Persistent Atrial Fibrillation

Abstract

Background-Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging can be used to evaluate characteristics of atrial fibrosis. The novel noninvasive epicardial and endocardial electrophysiology system (NEEES) allows for the identification of sources with rotor activity. This study describes a new technique to examine the relationship between rotors and LGE signal intensity in patients with persistent atrial fibrillation (PERS) scheduled for ablation. Methods and Results-Ten consecutive patients underwent pulmonary vein isolation for persistent atrial fibrillation.LGE CMR of both atria was performed, and NEEES-based analysis was conducted to identify rotors. For each mapping point, the intracardiac locations were transferred onto an individual CMR-derived 3-dimensional shell. This allowed the LGE signal intensity to be projected onto the anatomy from the NEEES analysis. NEEES analysis identified a total number of 410 electric rotors, 47.8% were located in the left atrium and 52.2% in the right atrium. Magnetic resonance imaging analysis was performed from 10 right atria and 10 left atria data sets, including 86 axial LGE CMR planes per atrium. The mean LGE burden for left atrium and right atrium was 23.9±1.6% and 15.9±1.8%, respectively. Statistical analysis demonstrated a lack of regional association between the extent of LGE signal intensity and the presence of rotors. Conclusions-This is the first study demonstrating that the presence of rotors based on NEEES analysis is not directly associated with the extent and anatomic location of LGE signal intensity from CMR. Further studies evaluating the relationship between rotors and fibrosis in patients with persistent atrial fibrillation are mandatory and may inform strategies to improve ablation outcome. (Circ Arrhythm Electrophysiol. 2017;10:e004419.

Heterogeneity of the action potential duration is required for sustained atrial fibrillation

“…Atrial fibrosis has been proposed as one mechanism for rotor clustering, and whereas a correlation between the amount of late gadolinium enhancement detected by MRI and the number of regions exhibiting reentry has been shown (8), other studies have found no such correlation (9,10). A role for APD heterogeneity in the genesis of rotors has been shown in in vitro cell culture studies of virally transduced ventricular myocyte monolayers variably expressing the hERG (human ether-a-gogo-related gene) protein in neonatal rats.…”

Innovations in Clinical Cardiac Electrophysiology: Challenges and Upcoming Solutions in 2018 and Beyond

“…Catheters with close inter-electrode Two hundred twenty-four unipolar surface electrodes are used to acquire electrograms that are projected on magnetic resonance imaging atrial shells to detect rotors. 132,133 FIRM: focal impulse and rotor mapping; 3D: three-dimensional. spacing resulting in improved spatial resolution may enhance our ability to detect rotors with confidence.…”

Verification of threshold for image intensity ratio analyses of late gadolinium enhancement magnetic resonance imaging of left atrial fibrosis in 1.5T scans

“…Late gadolinium enhancement is today a well-established method for detecting fibrosis in the ventricular myocardium [2]. Since its introduction in 2007 [3], CMR imaging of left atrial fibrosis with late gadolinium enhancement (LA LGE) has received increasing interest [4][5][6][7][8][9]. The method has proven valuable in detection of pre-ablation atrial fibrosis [4,8,[10][11][12][13] but also in evaluation of ablation procedures and detection of possible gaps in ablation lines after pulmonary vein isolation [10,12,[14][15][16].…”

“…Despite its many promising possibilities, LA LGE has remained a method reserved for highly specialized centres and previous studies have reported both positive [4,8,14,15] as well as disappointing results [5,7,[16][17][18][19]. The clinical adoption of LA LGE has been slowed by complex image acquisition protocols reflected in high exclusion rates of scans in clinical studies (9-32%) [4,5,8,9,13,20] and furthermore of a lack of consensus on an objective image analysis method [21].…”